Surgical EmergenciesSurgical Emergencies
Mr. Paul MacKenzie BSc (Hons), BM BS, MRCS
CT 2 Surgical Trainee
Royal Devon and ...
Saturday Morning at the RD&ESaturday Morning at the RD&E
You’re feeling a bit worse for wear from the
Mess Night Out.
Yo...
““FEEL FREETO COPE”FEEL FREETO COPE”
This is how to survive……..
9.30 am Dorothy9.30 am Dorothy
85-year-old –
Residential Home
Resident
Sudden Onset
Abdominal Pain at
7.30am
Confused
...
Assess The Patient in an ABCAssess The Patient in an ABC
MannerManner
A – Patent and Protected
B – Good Air entry bilate...
E – Abdomen diffusely Tender
◦ Feels Rigid
◦ Guarding
◦ Rebound Tenderness
◦ Patient is Lying Completely Still – Any
atte...
CXR (Portable)CXR (Portable)
What is the abnormality on theWhat is the abnormality on the
CXR? (1)CXR? (1)
A – Left Lower Lobe Pneumonia
B – Tension ...
ECGECG
What Does the ECG Show (2)What Does the ECG Show (2)
A – Atrial Flutter
B – Ventricular Flutter
C – Atrial Fibrillation...
ABGABG
How would you describe the ABG?How would you describe the ABG?
(3)(3)
A – Metabolic Alkylosis
B – Metabolic Acidosis
C ...
Differential Diagnosis?Differential Diagnosis?
What is the most likely Diagnosis?What is the most likely Diagnosis?
(4)(4)
A – Bowel Obstruction
B – Diverticulitis
C ...
ManagementManagement
Call for Senior Help!
Stabilise the patient
◦ IVI
◦ IVABx
◦ Catheterise
◦ Oxygen
Take Bloods (Inc....
11am Abigail
23-year-old
Sudden Onset Severe
Central Abdominal
Pain
Recent Laparoscopy
for Investigation of
Pelvic Pain...
Abigail’s pain moves to the RIF overAbigail’s pain moves to the RIF over
24 hours, she has a low grade24 hours, she has a ...
Abigail’s pain moves to the RIF overAbigail’s pain moves to the RIF over
24 hours, she has a low grade24 hours, she has a ...
Abigail’s pain moves to the RIF overAbigail’s pain moves to the RIF over
24 hours, she has a low grade24 hours, she has a ...
11am Abigail
23-year-old
Sudden Onset Severe
Central Abdominal
Pain
Recent Laparoscopy
for Investigation of
Pelvic Pain...
ABC Assessment
A- Patent and Protected
B – RR 20, Sats 98% Air
C – BP 100/80, HR 120
D – NAD
E – Abdomen Distended, t...
Elicit a good history!
Background & PMHx
◦ When was the laparoscopy?
◦ Who By?
◦ Read the Op note… Complications
◦ Any Me...
Investigations
Bedside – Urine Dip & BHCG
Bloods – ABG, FBC, UE’s, LFT’s,
Amylase, CRP
Imaging – Erect CXR
Management
Call For Help!
If Stable Enough – Likely Pat Will Need
CT – You can request these on Medway
If Unstable, Pat...
12pm Barry
77-year-old
Gradual Onset,
Lower Abdominal
Pain, came on over
few days, getting
worse
Distended, not
opening...
The Significance of Past Medical History!
Barry had an Open Resection of a sigmoid
Tumour 4 years ago
Barry has Motor Ne...
The Importance of Cllinical Examination
PR and Listen for Bowel Sounds!
Investigations
Bedside – Urine Dip
Bloods – FBC, UE’s, LFT’s CRP, TRACE
ELEMENTS, Mg, Phosphate, Calcium
CXR/AXR
?CT
Management
CT Scan – To identify point and Cause of
Obstruction
Conservative vs Surgical Management
Concept of ‘Drip an...
2pm Laura
55-year-old
Grumbling RUQ pain
last 48 hours
Now much worse
Central, radiating
through to the back
Associate...
What Endocrine Hormones doe theWhat Endocrine Hormones doe the
Pancreas Produce? (1)Pancreas Produce? (1)
A – Cholecystok...
What is the most common causeWhat is the most common cause
for pancreatitis? (3)for pancreatitis? (3)
A – Trauma
B – Alc...
GET SMASHED
G – Gallstones (45%)
E – Ethanol (35%)
T – Tumours
S – Scorpian Stings
M – Mumps (or Microbiology)
A – A...
Modified Glasgow Score (Score 1 for)
P – pO2 < 8
A – Age 55>
N – White Cell Count 15>
C – Calcium <2
R – Urea 16>
E ...
Management
?ITU
CXR
USS
Catheterise
Aggressive Fluid Management
?IVABx
CT after 5 days – Surgery only indicated
in ...
3pm Mark
67-year-old fit tennis
player
Sudden Onset Severe
Loin to Groin Pain
after a tennis match
Caused him to
Collap...
What is the most likely Diagnosis?What is the most likely Diagnosis?
(4)(4)
A – UTI
B - Renal Calculi
C – Inguinal Hern...
What is the most ImportantWhat is the most Important
Diagnosis to Exclude? (3)Diagnosis to Exclude? (3)
A – UTI
B - Rena...
What is the most Important FirstWhat is the most Important First
Line Investigation? (2)Line Investigation? (2)
A – CXR
...
ABC Assessment
A – Patent and Protected
B – RR 16, Sats 96% Air
C – BP 110/65, HR 98
D – NAD
E – Tender in lower abdo...
BUT…… 30 minutes later
A- Patent and Protected
B – RR 24, Sats 95% air
C – BP 80/40, HR 128
D – GCS 13/15
E – Abdomen...
What is the definitive Investigation?What is the definitive Investigation?
(5)(5)
A – CT Angiogram Aorta
B – MR Angiogra...
Management
Urgent Vascular Surgery Review – Needs
to be in theatre NOW!
Cross Match (at least) 4 units – Activate
Massiv...
Causes of Abdominal PainCauses of Abdominal Pain
Key Surgical EmergenciesKey Surgical Emergencies
Ischaemic Bowel
AAA
Perforation
Bowel Obstruction
Peritonitis
Pancr...
Key Points for Doing Well in AMKKey Points for Doing Well in AMK
Work hard and revise all year – this
exam is not designe...
Surgical emergencies yr 5 amk teaching
Surgical emergencies yr 5 amk teaching
Surgical emergencies yr 5 amk teaching
Surgical emergencies yr 5 amk teaching
Surgical emergencies yr 5 amk teaching
Surgical emergencies yr 5 amk teaching
Surgical emergencies yr 5 amk teaching
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Surgical emergencies yr 5 amk teaching

  1. 1. Surgical EmergenciesSurgical Emergencies Mr. Paul MacKenzie BSc (Hons), BM BS, MRCS CT 2 Surgical Trainee Royal Devon and Exeter Hospital
  2. 2. Saturday Morning at the RD&ESaturday Morning at the RD&E You’re feeling a bit worse for wear from the Mess Night Out. You’ve just finished Post Take Ward Round and are dutifully updating the Consultants list and putting out bloods that your colleague for got to do the night before. The Consultant, Registrar and SHO are all in theatre and are going to be a while…….. You wished you stayed in bed and phoned in sick…….
  3. 3. ““FEEL FREETO COPE”FEEL FREETO COPE” This is how to survive……..
  4. 4. 9.30 am Dorothy9.30 am Dorothy 85-year-old – Residential Home Resident Sudden Onset Abdominal Pain at 7.30am Confused Clammy In the Ambulance passed a small amount of PR Blood
  5. 5. Assess The Patient in an ABCAssess The Patient in an ABC MannerManner A – Patent and Protected B – Good Air entry bilaterally ◦ Sats 95% on Air ◦ Respiratory Rate 25 C – Cold, Clammy Peripherally Shut Down ◦ BP 85/70 ◦ HR 135 D – Confused ◦ GCS 13/15 ◦ Moving All four Limbs
  6. 6. E – Abdomen diffusely Tender ◦ Feels Rigid ◦ Guarding ◦ Rebound Tenderness ◦ Patient is Lying Completely Still – Any attempts to move her and she screams ◦ PR Examination – Empty Rectum, small amount altered blood on the glove
  7. 7. CXR (Portable)CXR (Portable)
  8. 8. What is the abnormality on theWhat is the abnormality on the CXR? (1)CXR? (1) A – Left Lower Lobe Pneumonia B – Tension Pneumothorax C – Tissue Heart Valve D – Coronary Artery Bypass Grafts D – Metallic Heart Valve
  9. 9. ECGECG
  10. 10. What Does the ECG Show (2)What Does the ECG Show (2) A – Atrial Flutter B – Ventricular Flutter C – Atrial Fibrillation D – Ventricular Fibrillation E – Supraventricular Tachycardia
  11. 11. ABGABG
  12. 12. How would you describe the ABG?How would you describe the ABG? (3)(3) A – Metabolic Alkylosis B – Metabolic Acidosis C – Respiratory Alkylosis D – Respiratory Acidosis E – Mixed Metabolic/Respiratory Acidosis
  13. 13. Differential Diagnosis?Differential Diagnosis?
  14. 14. What is the most likely Diagnosis?What is the most likely Diagnosis? (4)(4) A – Bowel Obstruction B – Diverticulitis C – Appendicitis D – Ischaemic Bowel E – Ruptured AAA
  15. 15. ManagementManagement Call for Senior Help! Stabilise the patient ◦ IVI ◦ IVABx ◦ Catheterise ◦ Oxygen Take Bloods (Inc. G+S) CT Scan + ? Laparotomy
  16. 16. 11am Abigail 23-year-old Sudden Onset Severe Central Abdominal Pain Recent Laparoscopy for Investigation of Pelvic Pain – Likely due to retrograde menstruation
  17. 17. Abigail’s pain moves to the RIF overAbigail’s pain moves to the RIF over 24 hours, she has a low grade24 hours, she has a low grade temperature and vomits once. Shetemperature and vomits once. She has a high WCC and CRP. What ishas a high WCC and CRP. What is the most likely diagnosis? (3)the most likely diagnosis? (3) A – Renal Colic B – Ruptured Ectopic Pregnancy C – Ovarian Cyst Accident D – Retrograde Mentruation E – Appendicitis
  18. 18. Abigail’s pain moves to the RIF overAbigail’s pain moves to the RIF over 24 hours, she has a low grade24 hours, she has a low grade temperature and vomits once. Shetemperature and vomits once. She has Normal Bloods. What is thehas Normal Bloods. What is the most Likely Diagnosis? (4)most Likely Diagnosis? (4) A – Renal Colic B – Ruptured Ectopic Pregnancy C – Ovarian Cyst Accident D – Retrograde Mentruation E – Appendicitis
  19. 19. Abigail’s pain moves to the RIF overAbigail’s pain moves to the RIF over 24 hours, she has a low grade24 hours, she has a low grade temperature and vomits once.temperature and vomits once. What is the most ImportantWhat is the most Important Diagnosis to Exclude? (5)Diagnosis to Exclude? (5) A – Renal Colic B – Ruptured Ectopic Pregnancy C – Ovarian Cyst Accident D – Retrograde Mentruation E – Appendicitis
  20. 20. 11am Abigail 23-year-old Sudden Onset Severe Central Abdominal Pain Recent Laparoscopy for Investigation of Pelvic Pain – Likely due to retrograde menstruation
  21. 21. ABC Assessment A- Patent and Protected B – RR 20, Sats 98% Air C – BP 100/80, HR 120 D – NAD E – Abdomen Distended, tender in Epigastrium with rebound tenderness and guarding
  22. 22. Elicit a good history! Background & PMHx ◦ When was the laparoscopy? ◦ Who By? ◦ Read the Op note… Complications ◦ Any Medications? ◦ Gynae History Presentation ◦ Onset of Pain, Nature of Pain, Radiation
  23. 23. Investigations Bedside – Urine Dip & BHCG Bloods – ABG, FBC, UE’s, LFT’s, Amylase, CRP Imaging – Erect CXR
  24. 24. Management Call For Help! If Stable Enough – Likely Pat Will Need CT – You can request these on Medway If Unstable, Patient will Need Laparotomy – You can help get things ready – Check G&S, Check Antibiotics Rx’d, Inform theatres and liaise , Catheterise
  25. 25. 12pm Barry 77-year-old Gradual Onset, Lower Abdominal Pain, came on over few days, getting worse Distended, not opening bowels and not passing wind for 48 hours
  26. 26. The Significance of Past Medical History! Barry had an Open Resection of a sigmoid Tumour 4 years ago Barry has Motor Neurone Disease Barry has had a recent Urinary Tract Infection Barry has had a recent nasty Chest Infection Barry is awaiting a hip replacement and has severe pain from Osteoarthrtitis
  27. 27. The Importance of Cllinical Examination PR and Listen for Bowel Sounds!
  28. 28. Investigations Bedside – Urine Dip Bloods – FBC, UE’s, LFT’s CRP, TRACE ELEMENTS, Mg, Phosphate, Calcium CXR/AXR ?CT
  29. 29. Management CT Scan – To identify point and Cause of Obstruction Conservative vs Surgical Management Concept of ‘Drip and Suck’ – NG tube and Catheterise
  30. 30. 2pm Laura 55-year-old Grumbling RUQ pain last 48 hours Now much worse Central, radiating through to the back Associated with nausea and vomiting Sweaty and Clammy
  31. 31. What Endocrine Hormones doe theWhat Endocrine Hormones doe the Pancreas Produce? (1)Pancreas Produce? (1) A – Cholecystokinin B – Amylase C – Lipase D – Insulin and Glucagon E – Serotonin
  32. 32. What is the most common causeWhat is the most common cause for pancreatitis? (3)for pancreatitis? (3) A – Trauma B – Alcohol C – Gallstones D – Scorpian Stings E - Tumours
  33. 33. GET SMASHED G – Gallstones (45%) E – Ethanol (35%) T – Tumours S – Scorpian Stings M – Mumps (or Microbiology) A – Autoimmune S – Surgery/Trauma/ERCP H – Hyperlipidaemia/Metabolic E – Emboli/Ischaemia D – Drugs/Toxins
  34. 34. Modified Glasgow Score (Score 1 for) P – pO2 < 8 A – Age 55> N – White Cell Count 15> C – Calcium <2 R – Urea 16> E – LDH 600>, AST/ALT >200 A – Albumin <32 S – Blood Glucose >10
  35. 35. Management ?ITU CXR USS Catheterise Aggressive Fluid Management ?IVABx CT after 5 days – Surgery only indicated in Severe Cases where necrosis is present
  36. 36. 3pm Mark 67-year-old fit tennis player Sudden Onset Severe Loin to Groin Pain after a tennis match Caused him to Collapse Past Medical History – Previous Renal Colic and Hypertension
  37. 37. What is the most likely Diagnosis?What is the most likely Diagnosis? (4)(4) A – UTI B - Renal Calculi C – Inguinal Hernia D – Femoral Hernia E – Ruptured AAA
  38. 38. What is the most ImportantWhat is the most Important Diagnosis to Exclude? (3)Diagnosis to Exclude? (3) A – UTI B - Renal Calculi C – Inguinal Hernia D – Femoral Hernia E – Ruptured AAA
  39. 39. What is the most Important FirstWhat is the most Important First Line Investigation? (2)Line Investigation? (2) A – CXR B – AXR C – FAST Scan C – Urine Analysis D – Full Blood COunt
  40. 40. ABC Assessment A – Patent and Protected B – RR 16, Sats 96% Air C – BP 110/65, HR 98 D – NAD E – Tender in lower abdomen and right flank & renal angle
  41. 41. BUT…… 30 minutes later A- Patent and Protected B – RR 24, Sats 95% air C – BP 80/40, HR 128 D – GCS 13/15 E – Abdomen tender ?More distended
  42. 42. What is the definitive Investigation?What is the definitive Investigation? (5)(5) A – CT Angiogram Aorta B – MR Angiogram C – USS D – FAST Scan E – Plain CT
  43. 43. Management Urgent Vascular Surgery Review – Needs to be in theatre NOW! Cross Match (at least) 4 units – Activate Massive Transfusion Protocol Permissive Hypotension – Don’t Ram him full of Fluids Catheterise Going to need Arterial Line/ Central Line etc. So Let Anaesythetics team know!
  44. 44. Causes of Abdominal PainCauses of Abdominal Pain
  45. 45. Key Surgical EmergenciesKey Surgical Emergencies Ischaemic Bowel AAA Perforation Bowel Obstruction Peritonitis Pancreatitis Acute GI Bleed Ischaemic Limb
  46. 46. Key Points for Doing Well in AMKKey Points for Doing Well in AMK Work hard and revise all year – this exam is not designed to be ‘revised for’ READ THE QUESTION CAREFULLY If you can narrow the answer down to two – its worth a shot Take a night off the night before the exam
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